Provider Demographics
NPI:1720872146
Name:CLARK, VERONICA LAKE (MOTR/L,CLT)
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:LAKE
Last Name:CLARK
Suffix:
Gender:
Credentials:MOTR/L,CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 NEW MARKET BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5501
Mailing Address - Country:US
Mailing Address - Phone:828-355-9584
Mailing Address - Fax:828-355-9689
Practice Address - Street 1:450 NEW MARKET BLVD STE 3
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5501
Practice Address - Country:US
Practice Address - Phone:828-355-9584
Practice Address - Fax:828-355-9689
Is Sole Proprietor?:No
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NC17100225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No174400000XOther Service ProvidersSpecialist